COMSAE Phase 2 Form 112 Exam 2026: 179 Practice Questions
with Verified Answers & Rationales – COMLEX-USA Level 2-CE
Prep| Instant Download Pdf
Exam Overview: The COMSAE Phase 2 Form 112 is a self-assessment examination
offered by the NBOME to help osteopathic medical students evaluate their readiness for the
COMLEX-USA Level 2-CE examination . The exam focuses on clinical decision-making,
diagnosis, and management across all major clinical disciplines with an emphasis on real-
world application . Each form includes 176 items divided into four sections of 44 questions
each and costs $60 .
EXAM FORMAT & BLUEPRINT
Feature Detail
Content Clinical Medicine (diagnosis, management, pathophysiology, clinical
Covered reasoning)
Question Clinical vignette-based multiple-choice with single best answer
Style
Blueprint COMLEX-USA Level 2-CE (Internal Medicine 20-25%, Surgery 10-15%,
OB/GYN 8-12%, Pediatrics 8-12%, Psychiatry 8-12%, Neurology 8-
12%, Emergency Medicine 8-12%, OMM 8-12%, Preventive Medicine 5-
10%)
SECTION 1: INTERNAL MEDICINE (Questions 1-40)
Q1. A 58-year-old man with hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain radiating to the back. Blood pressure is 150/90 in
the right arm and 110/70 in the left arm. What is the most appropriate next step?
Answer: Obtain computed tomography angiography (CTA) of the chest
Rationale: The presentation (tearing chest pain, blood pressure differential between arms)
is highly suggestive of aortic dissection. CT angiography is the definitive imaging study for
,diagnosis and surgical planning . Sublingual nitroglycerin or ECG could delay diagnosis,
and fibrinolytics are contraindicated in aortic dissection .
Q2. A 72-year-old woman is brought in with progressive forgetfulness, apathy, and
difficulty walking over 6 months. She has urinary incontinence. On exam, she has a
magnetic gait. What is the most likely diagnosis?
Answer: Normal pressure hydrocephalus (NPH)
Rationale: The classic triad of dementia (forgetfulness, apathy), gait disturbance (magnetic
gait), and urinary incontinence is characteristic of normal pressure hydrocephalus.
Alzheimer's disease typically does not present with gait disturbance and incontinence early
in the course .
Q3. A 55-year-old man with history of alcohol use disorder presents with jaundice,
ascites, and fever. Labs: AST 180, ALT 75, bilirubin 8.5, INR 1.8. Maddrey's
discriminant function is 45. What is the most appropriate treatment?
Answer: Prednisolone
Rationale: Severe alcoholic hepatitis (Maddrey's discriminant function >32) is treated with
prednisolone to reduce inflammation and mortality. N-acetylcysteine is for acetaminophen
toxicity; rifaximin is for hepatic encephalopathy; spironolactone treats ascites but is not the
primary treatment .
Q4. A 62-year-old male with type 2 diabetes, hypertension, and CKD stage 3 presents
with progressive fatigue and dyspnea on exertion. Hb 8.9 g/dL, MCV 78 fL, ferritin 450
ng/mL, TIBC 210 μg/dL, serum iron 85 μg/dL. What is the most likely diagnosis?
Answer: Anemia of chronic disease (ACD)
Rationale: ACD is common in CKD, diabetes, and hypertension. Ferritin is normal/elevated,
TIBC low/normal, and MCV normocytic or mildly microcytic. Iron deficiency would show low
ferritin and high TIBC .
, Q5. A 55-year-old female presents with acute-onset severe chest pain that is sharp,
pleuritic, and relieved by leaning forward. BP 140/85, HR 102. Faint pericardial friction
rub heard. ECG shows diffuse ST elevations and PR depression. Troponin I 0.08
ng/mL (normal <0.04). Which medication is contraindicated?
Answer: Ibuprofen
Rationale: The presentation is pericarditis. While NSAIDs (ibuprofen) are first-line for
pericarditis, they should be avoided in patients with coexisting myocardial injury (troponin
elevation suggests possible myopericarditis). In this scenario, NSAIDs could worsen
myocardial injury. Corticosteroids may be used in refractory cases but are not first-line .
Q6. A 65-year-old man presents with chest pain radiating to the left arm. Which
enzyme rises first in myocardial infarction?
Answer: Myoglobin
Rationale: Myoglobin rises earliest (1–3 hours) in acute MI but is nonspecific. Troponin is
the most specific biomarker .
Q7. A patient with COPD develops worsening dyspnea and elevated PaCO₂. What is
the BEST initial management?
Answer: Non-invasive positive pressure ventilation (NPPV/BiPAP)
Rationale: BiPAP reduces CO₂ retention and work of breathing. High-flow oxygen alone
may worsen hypercapnia in COPD patients with chronic CO₂ retention .
Q8. A 50-year-old man with chronic kidney disease stage 4 presents with bone pain
and serum calcium 8.5 mg/dL, phosphorus 6.2 mg/dL, PTH 450 pg/mL. What is the
most appropriate initial therapy?
Answer: Sevelamer carbonate
Rationale: Hyperphosphatemia in CKD-MBD requires phosphate binders first. Sevelamer
(non-calcium) lowers phosphorus without increasing calcium load. Calcium acetate would
add calcium; cinacalcet lowers PTH but not phosphorus; calcitriol may worsen
hyperphosphatemia .
with Verified Answers & Rationales – COMLEX-USA Level 2-CE
Prep| Instant Download Pdf
Exam Overview: The COMSAE Phase 2 Form 112 is a self-assessment examination
offered by the NBOME to help osteopathic medical students evaluate their readiness for the
COMLEX-USA Level 2-CE examination . The exam focuses on clinical decision-making,
diagnosis, and management across all major clinical disciplines with an emphasis on real-
world application . Each form includes 176 items divided into four sections of 44 questions
each and costs $60 .
EXAM FORMAT & BLUEPRINT
Feature Detail
Content Clinical Medicine (diagnosis, management, pathophysiology, clinical
Covered reasoning)
Question Clinical vignette-based multiple-choice with single best answer
Style
Blueprint COMLEX-USA Level 2-CE (Internal Medicine 20-25%, Surgery 10-15%,
OB/GYN 8-12%, Pediatrics 8-12%, Psychiatry 8-12%, Neurology 8-
12%, Emergency Medicine 8-12%, OMM 8-12%, Preventive Medicine 5-
10%)
SECTION 1: INTERNAL MEDICINE (Questions 1-40)
Q1. A 58-year-old man with hypertension and type 2 diabetes presents with acute
onset of severe, tearing chest pain radiating to the back. Blood pressure is 150/90 in
the right arm and 110/70 in the left arm. What is the most appropriate next step?
Answer: Obtain computed tomography angiography (CTA) of the chest
Rationale: The presentation (tearing chest pain, blood pressure differential between arms)
is highly suggestive of aortic dissection. CT angiography is the definitive imaging study for
,diagnosis and surgical planning . Sublingual nitroglycerin or ECG could delay diagnosis,
and fibrinolytics are contraindicated in aortic dissection .
Q2. A 72-year-old woman is brought in with progressive forgetfulness, apathy, and
difficulty walking over 6 months. She has urinary incontinence. On exam, she has a
magnetic gait. What is the most likely diagnosis?
Answer: Normal pressure hydrocephalus (NPH)
Rationale: The classic triad of dementia (forgetfulness, apathy), gait disturbance (magnetic
gait), and urinary incontinence is characteristic of normal pressure hydrocephalus.
Alzheimer's disease typically does not present with gait disturbance and incontinence early
in the course .
Q3. A 55-year-old man with history of alcohol use disorder presents with jaundice,
ascites, and fever. Labs: AST 180, ALT 75, bilirubin 8.5, INR 1.8. Maddrey's
discriminant function is 45. What is the most appropriate treatment?
Answer: Prednisolone
Rationale: Severe alcoholic hepatitis (Maddrey's discriminant function >32) is treated with
prednisolone to reduce inflammation and mortality. N-acetylcysteine is for acetaminophen
toxicity; rifaximin is for hepatic encephalopathy; spironolactone treats ascites but is not the
primary treatment .
Q4. A 62-year-old male with type 2 diabetes, hypertension, and CKD stage 3 presents
with progressive fatigue and dyspnea on exertion. Hb 8.9 g/dL, MCV 78 fL, ferritin 450
ng/mL, TIBC 210 μg/dL, serum iron 85 μg/dL. What is the most likely diagnosis?
Answer: Anemia of chronic disease (ACD)
Rationale: ACD is common in CKD, diabetes, and hypertension. Ferritin is normal/elevated,
TIBC low/normal, and MCV normocytic or mildly microcytic. Iron deficiency would show low
ferritin and high TIBC .
, Q5. A 55-year-old female presents with acute-onset severe chest pain that is sharp,
pleuritic, and relieved by leaning forward. BP 140/85, HR 102. Faint pericardial friction
rub heard. ECG shows diffuse ST elevations and PR depression. Troponin I 0.08
ng/mL (normal <0.04). Which medication is contraindicated?
Answer: Ibuprofen
Rationale: The presentation is pericarditis. While NSAIDs (ibuprofen) are first-line for
pericarditis, they should be avoided in patients with coexisting myocardial injury (troponin
elevation suggests possible myopericarditis). In this scenario, NSAIDs could worsen
myocardial injury. Corticosteroids may be used in refractory cases but are not first-line .
Q6. A 65-year-old man presents with chest pain radiating to the left arm. Which
enzyme rises first in myocardial infarction?
Answer: Myoglobin
Rationale: Myoglobin rises earliest (1–3 hours) in acute MI but is nonspecific. Troponin is
the most specific biomarker .
Q7. A patient with COPD develops worsening dyspnea and elevated PaCO₂. What is
the BEST initial management?
Answer: Non-invasive positive pressure ventilation (NPPV/BiPAP)
Rationale: BiPAP reduces CO₂ retention and work of breathing. High-flow oxygen alone
may worsen hypercapnia in COPD patients with chronic CO₂ retention .
Q8. A 50-year-old man with chronic kidney disease stage 4 presents with bone pain
and serum calcium 8.5 mg/dL, phosphorus 6.2 mg/dL, PTH 450 pg/mL. What is the
most appropriate initial therapy?
Answer: Sevelamer carbonate
Rationale: Hyperphosphatemia in CKD-MBD requires phosphate binders first. Sevelamer
(non-calcium) lowers phosphorus without increasing calcium load. Calcium acetate would
add calcium; cinacalcet lowers PTH but not phosphorus; calcitriol may worsen
hyperphosphatemia .
